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Week 1 PleuralDisease - 30 Oktober 2012
Week 1 PleuralDisease - 30 Oktober 2012
Definisi
Pneumothorax
Pleural effusion:
Transudates/exudates, hematothorax,
cylothorax /pseudocylothorax,
empyema, pleural effusion in spesific
diseases (SLE, e.t.c )
Pleural tumors
Pleurisy (pleural inflammation)
Empyema
Empyema is pus in the pleural cavity; it
consists of polymorphonuclear leukocytes
and fibrin.
caused an infection
Risk factors include :
bacterial pneumonia, lung abscess,
thoracic surgery, trauma or injury to the
chest, or rarely, thoracentesis.
Prevalence
Pathophysiology
From: Cretien, J, Bignon, J., Hirsch, A, eds: The Pleura in Health and Disease.
New York: Marcel Dekker, 1985, p182.
Diagnosis
Ultrasound
Glucose
Very low glucose levels ( 25 mg/100
mL), although not pathognomonic, are
seen in a few diseases.
Rheumatoid arthritis, tuberculosis,
empyema, and tumors or malignancy
very low glucose levels.
Amylase
Elevated pleural fluid amylase is seen
with pancreatitis and esophageal rupture
and in approximately 10% of malignant
effusions.
pH
Normal pleural fluid pH : 7.64.
- pH 7.30 inflammatory or infiltrative
process ( parapneumonic effusions,
empyema, malignancy, connective tissue
diseases, tuberculosis, and esophageal
rupture.
- Urinothorax is peculiar in that it is the
only cause of a low pH transudative
effusion.
Pleural Fluid
Bacteriology
Pleural
Fluid
Chemistry
Need
for
Drainag
e
Cx and GS
unknown
pH unknown
No
Negative Cx
and GS
pH > 7.20
No
Positive Cx or
GS
pH < 7.20
Yes
Any
Pus
pH < 7.0
Yes
Adenosine Deaminase
Adenosine deaminase levels 70 U/L is
highly suggestive of tuberculous pleuritis,
whereas a level less than 40 U/L virtually
rules out this diagnosis.
Other pleural diseases : adenosine
deaminase rheumatoid pleuritis and
empyema
Pleural Biopsy
The use of an Abrams needle to obtain
specimens from the parietal pleura has
become less common with the increasing
availability of improved serum markers
and thoracoscopy.
Needle biopsy of the pleura to diagnose
tuberculous pleuritis when other markers
(e.g., adenosine deaminase) are
negative.
Thoracoscopy
Invasive techniques for the diagnosis of pleural effusions
video-assisted technology (VATS).
Thoracoscopy :
- visual evaluation of the pleura,
- direct tissue sampling, and
- therapeutic intervention (e.g., dissecting loculations and
pleurodesis).
Medical thoracoscopy (performed by pulmonologists under
conscious sedation) and video-assisted thoracoscopic
surgery (VATS), which is performed by surgeons under
general anesthesia, are indicated for diagnosing pleural
effusions that have remained undiagnosed despite
previous, less-invasive tests (e.g., thoracentesis).
Diagnosis of Pleural
Effusion
Therapeutic Thoracentesis
Drainage of a pleural effusion indicated in complicated
parapneumonic effusions or empyema for symptomatic
relief of dyspnea, and to evaluate underlying lung
parenchyma (pleural fluid bacteriology (culture and Gram
stain), and pleural fluid chemistry (pH)).
Therapeutic thoracentesis at any one time, no more
than 1 L to 1.5 L of fluid should be removed (unless
pleural space pressure is monitored) to avoid reexpansion pulmonary edema and post-thoracentesis
shock.
Supplemental oxygen because post-thoracentesis
decreases in arterial oxygenation
Surgery
complicated pleural effusions parietal
pleurectomy and decortication of the
visceral pleura.
(the patient's general medical condition,
expected long-term prognosis, and
baseline lung function should be
considered before proceeding with
surgery)
responsive to corticosteroids.
Malignancy
neoplastic disease metastasis than through
primary tumors.
- Lung and breast cancers metastatic disease
to
the pleura. Other less common causes are
hematologic (e.g., lymphoma, leukemia),
ovarian, and gastrointestinal tumors.
- Cytologic of the pleural fluid positive ( 50%
of cases )
- Tumor markers (e.g., carcinoembryonic antigen
[CEA] are not specific enough.
- Immunocytometry the diagnosis of lymphoma
Chylothorax
Leakage of chyle from a disruption of the
thoracic duct leads to a chylothorax.
milky fluid measuring pleural fluid
triglyceride levels
- A triglyceride 110 mg/dL confirms the
diagnosis, whereas 40 mg/dL excludes the
diagnosis.
- chylomicrons in the effusion (using
electrophoresis) establishes the diagnosis.
Hemothorax
pleural fluid is bloody the pleural fluid
hematocrit 50% of the peripheral blood
hematocrit.
Hemothorax most commonly results from chest
trauma.
Nontraumatic hemothorax malignancy or
pulmonary embolism.
pleural
cavity
Types of pneumothorax
Open pneumothorax
Spontaneous pneumothorax
Tension pneumothorax
Collapse of ipsilateral lung due to
pressure change & disruption of
surface tension
Potential for mediastinal shifts
pneumothorax
Classification of Pneumothorax
Traumatic or iatrogenic
Spontaneous (without antecedent cause):
Primary (no underlying lung pathology)
Secondary (underlying lung pathology)
Management of Spontaneous
Pneumothorax
Primary Spontaneous Pneumothorax
Stable Patients with Small Pneumothoraces
Observation in the emergency department for 3 to 6 hours
Discharge home if a repeat chest radiograph excludes progression
Follow up 12-48 hours with repeat chest radiograph resolution
Stable Patients with Large Pneumothoraces
Hospitalization
Re-expansion of lung using a small-bore catheter or placing a 1622 F chest tube
Suction if lung fails to re-expand
Unstable Patients with Large Pneumothoraces
Hospitalization
Chest tube placement with 16-22 F standard chest tube
Use 24-28 F chest tube if the patient has a large air leak or
requires positive-pressure ventilation
Summary
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